Pain Medicine - Science topic

I am interested in being part of the Advisory Board, my email: mpcalimag@ust.edu.ph

Dear Dr Laratta,

I am working on inflammatory neuropathies in alternative medicine. The results of treatments are perfect. But there is no any major article.) Are you intresting in scientific research or practical outcomes?

I have used the agent in selected cases of BPS, usually where urinary frequency is also present and contributing to the pain. The response in my patients has been inconsistent. The benefit, when seen, is transient. Would certainly consider it in patients that have failed conventional therapy.

If we assume that the stage of damage is the same for both joints, then we have to discuss the schedule with the patient and take into consideration his/her complaints. I would do first the more painful joint. On the other hand, we have to take into consideration  the possibility of referred pain from the hip that intensifies the knee complaints. If this is the case, then hip first and knee later. However, some surgeons make an association with the building or repair of an old house. It is always started  from the foundation or basement. So I think both variants are possible, and the surgeon (and patient !) should decide individually from case to case.

We published a paper in which we show an absolute ODI-value corresponding to patient acceptabel symptomen state (PASS) for the official ODI v.2.1a. An ODI <=22 equals PASS and seems corresponding to 'normal', healthy populations as well. I suggest to use ODI <=22 as a lower limit. Furthermore, it is known that a minimal clinical important difference is at least 10 points or 30% of the baseline value (Ostelo et al. 2008) and literature shows that an ODI >= 41 corresponds to longstanding chronicLBP. Hopefully, this information is of use.

Every day-  did i say every day !  I meant 2x a day... LOL. It's the most common thing I see .....

I agree with Sergey but due to many issues general anesthesia isn't possible.  With the elbow a small amount of sedation with a joint infiltration of local works great.  The shoulder if done correctly also is good with a sedation to relax the musculature.

Do you mean "osteoartritis" (inflamation of the joint) or "osteoarthrosis" (degeneration of the joint)? There is a big difference, as far as conseravtive or surgical treatment is also concerned. 

This is an interesting question. Maybe it is easier to answer with more information, e.g. is the anodynie a burning sensation too, or is it a different quality of pain? If both sensations are of burning quality, I would expect a neuropathy as the cause of painful sensation. Is the sensation chronic or does it only occur transiently in certain situations? Did the patients have other diseases, e.g. diabetic polyneuropathy? Did they take medication that might have caused this sensation as a side effect?

Based on the dermatome of the sole of the foot, one would expect L4 or S1, the anal region, on the other hand, is S3 to S5. You could be right that the proximity of the sacral nerves is responsible for this. Alternatively, you may consider the proximity of the genito-anal region and the foot in the somatosensory cortex (refer to map of neocortex).

Dear Khaled,

It is a pity that the full text is in German

Herold C, Fleischer O, Allert S. Autologous fat injection for treatment of carpometacarpal joint osteoarthritis of the thumb a promising alternative. Handchir Mikrochir Plast Chir 2014 Apr;46(2):108-12.

Pete Batcheller has written on Clusterheadache.com that "Regarding the optimum maintenance dose of vitamin D3... The best information available indicates the average sustained 25(OH)D response to a dose of 5,000 IU/day is 60 ng/mL while a maintenance dose of 10,000 IU/day results in a sustained average 25(OH)D response of 80 to 85 ng/mL."

I am unclear where these assertions come from, along with the variation in individual responses to the doses. 

Background: I treat pudendal neuropathy and the patients often have additional peripheral neuropathic pain generators. Patients have central sensitization. The sympathetic innervation of abdominal and pelvic viscera is referred to the thoracolumbar junction region of the spinal cord. Viscera lack somatic sensory innervation.

Thus patient with pudendal neuropathy may have colitis symptoms, irritable bladder, persistent genital arousal, etc.

Moreover, pressure on thoracic or abdominal cutaneous nerves at the rectus border can refer pains to viscera. Left T-8 caused a "tube of pain" to the vagina. T-10 caused urge to void. T-12 caused pain in the cervix.

These are but a few examples. The "pinch roll" maneuver of Maigne (TLJ syndrome) can cause pains in any viscera in various patients.

I would consider the sympathetic innervation, developing in the fetus, drives the focus of the visceral pain to the cord level of somites that produce the viscus.

email C4uppllc@gmail.com

the inflammation of the hemorrhoidal plexus can be supported by an altered intestinal microbiota with a loss of lactobacilli and bifidobacteria that lead to butyric acid production. .the absence of butyrate leads to an alteration of the tissue control system (PPAR alpha and Gamma able to block NfKB transcription) resulting in an inflammatory status that cause sensitization of afferent fibers due to prostaglandins. acidic pH also causes afferent fibers sensitization but makes available opioid receptors normally inactive, capable of responding to opiate drugs.

Thank you - I agree with your statement about RG. Knowing, though, what is being researched leads me to information I can take to my doctor for discussion regarding my person case.

At the same time, I am also researching chronic pain conditions and their relation to what's considered a mind/body split, and how a doctor's relationship with their patient might contribute to, or help to heal, a mind/body split. Are you familiar with any research and articles related to these subjects? 

you can use oswestry disability index and nordic musculoskeletel questionnaire 

Safety related to the use of codeine has been widely investigated both in Canada and United States. That is why I would not recommend using it especially with the North African population because of the high % of this population being ultra-metabolizers as you stated.

 Thank you very much Mr.Laslett

Dear Senthilkumar. You can reach the web:  www.iasp-pain.org, from the International Association for the Study of Pain, the most reliable, actualized and with a huge of evidence supported reports about several models  incluiding the biopsychosocial pain model.

Jin, I would read some of Stuart McGill's work.  His website is www.backfitpro.com and he is a professor at the University of Waterloo.  He does not recommend strengthening the spine through a range of motion with a load whether isokinetic of isotonic.  If the isokinectic exercise is done in a sitting position it places high load on the spine and if putting the spine through a range of motion (from flexion to neutral) reproduces the mechanism for herniating a disc (if done repeatedly).

Multimodal therapy is  recognized as a critical pain management approach, especially when combined with early nutrition and ambulation, designed to improve functional recovery and decrease chronic pain conditions. Multimodal therapy included a wide range of procedures and medications, including regional analgesia with continuous epidural or peripheral nerve block infusions,  opioids, acetaminophen, anti-inflammatory agents, anticonvulsants, ketamine, clonidine, mexiletine, antidepressants, and anxiolytics as options to treat or modulate pain at various sites of action

Thank you Jean Pierre, but I'm not looking for homeopathy...

I concur with the collective wisdom of learned colleagues, Dr. Kaell and Dr. Schiltenwolf  who underscore the very crux of the issue. They highlight the key reason I mentioned that interdisciplinary teams must consist of committed and dedicated individuals pulling together for the same goals rooted in the Hippocratic Oath (and the essential Princilpes of Ethics). At heart I trust that this is so when the best of us come together as committed human beings, scientists, and doctors who want to fulfil their central credo of healing, especially in multidisciplinary teams and also in our daily roles as doctors and healers, in hospitals or out in the community and / or facing special challenges.

However, for the reasons I mentioned earlier, our ability to deliver truly effective pain management is in danger and at the mercy of the various review boards, other structures, and shifting societal mores that seem to be around us over the past few years. Why? Because our care delivery, our goals of care, in fact our very credo, cannot be fulfilled in a vacuum.

Like it or not we are affected by forces and the shifting sands of opinions around us. I concur with Drs. Kaell and Schiltenwolf that the buy in of team members s essential to work in synergy towards effective outcomes. Yet, I think we must pause to remind ourselves that the central message, these central messages, we all have articulated on this page and in our practices, are in danger of obfuscation when so many ancillary individuals and structures carry the power to alter goals and messages. It is solely upto us as physicians and healers to keep raising the awareness regarding the rightful place of pain as the VITAL 5th vital sign that we must manage effectively with all the real / truly effective strategies at our disposal. Not only is this an important message to articulate and re-articulate by those of us "who have a voice on behalf of those who do not", it is also an important message with which to re-enthuse ourselves, our colleagues, and our mentees and students in order to achieve a true and collective faith in health CARE that our patients, especially those in intractable pain need, want, and yes, should receive.

Ketamina at the right dosage may be sufficient, especially in some situation, when more useful drugs are not available

Sorry Giustino but I can't answer the question ... I'm only an economist. However, I have a request for you and your colleagues on the status of modeled claims. I have just drafted a paper on economic evaluation articles published in Value in Health. I would appreciate any comments (and possible venues where these questions could be raised). With best wishes. Paul Langley

Hi Peter,

Very informative..... Thanks a lot.

Warm regards,

Hi,

absolutely right, depends on the kind of pain.

puls volume sensor at the temple for certain types of headache works for most patients.

a huge part of the patients who can be treated with biofeedback have chronic musculosceletal pain. EMG for tension related muscle pain, usually upper (trapezius) and lower (erector spinae) back as well as neck pain. another group of patients that might profit from biofeedback along with physiotherapy are pain patients with tension related pain or pain due to asymmetrical posture or gait after injury. Not sure how your machine is set up, but for EMG which is very effective, you might need 2 channels.

other measures:

most patients in a psychotherapeutical setting tense up because of psychological stressors. that is often accompanied by an increase in heart rate. that might be another variable to control that is not directly linked to the direct physiological cause of the pain. so by teaching subjects/patients to control their reaction to stress it might help them to alleviate pain.

hope that helps a little

I attach the refferences of some papers that expain the response to your question:

-Salom-Moreno J, Sánchez-Mila Z, Ortega-Santiago R, Palacios-Ceña M,

Truyol-Domínguez S, Fernández-de-las-Peñas C. Changes in spasticity, widespread

pressure pain sensitivity, and baropodometry after the application of dry

needling in patients who have had a stroke: a randomized controlled trial. J

Manipulative Physiol Ther. 2014 Oct;37(8):569-79.

-Chen ZM, Wu XT. [Clinical efficacy observation on primary trigeminal neuralgia

treated with joint needling method at the trigger point]. Zhongguo Zhen Jiu. 2012

Jun;32(6):499-502.

-Zeilig G, Rivel M, Weingarden H, Gaidoukov E, Defrin R. Hemiplegic shoulder

pain: evidence of a neuropathic origin. Pain. 2013 Feb;154(2):263-71.

As central as peripheral sensitization is presented in shoulder pain in relationship with myofascial trigger points.

Firstly ketamine does not work in the patient who is tissue magnesium depleted.   Therefore oral 1 week or IV 24 hours loading with Magnesium is required first.

 Best results are combining with Clonidine which usefully also blocks the ketamine induced tachycardia and hypertension.

Generally higher doses produce better results ie 40mg/hour but one has to titrate up slowly to have patients tolerate that.

Even so I find only 1/4 patients benefit from this advanced protocol treatment

In my experience in CRPS the psychological patient´s background  is crucial. The central mechanisms linked to the immunological and sympathetic nervous system might play a role. It´s necesary, specially  in a a young girl, to explore the personality traits and work in accordance to. Very important: reassure the patient. It´s the power of mind.!

I reckon that would depend on how long your experiment would be. If you need to measure only three time points after a treatment it would be ok to test them twice (morning and evening) on the first day and then 24 hrs later. However, if you are planning a longer experiment I would not recommend a daily testing schedule. Repeated testing (considering the long acclimatization time and testing time in mice) will cause stress and thus weight loss over time, which of course would be an animal welfare concern.

Hello David! I have another suggestion: the pain trajectory. This simple approach describes the pain of your patients with a regression line. 

I think this is one of the cases where the proverb fits: "shit in - shit out".

If the patients are not well informed and may differ in their understanding and attitude towards the scale, if the data obtained from is not comparable.

As long as you have no detailed information about all the paitents' understanding and motivation (e.g. what other patients served as "reference", and how precisely did they serve as reference, how did the patient "adjust" his choice etc) there won't be any sensible way to correct or normalize your data.

There is at least one very important thing one can learn from this experiment:

The quality of the data is fundamental for all further analysis. This quality depends much on the study design and the protocol (methods). Analysing/interpreting data without being sure that the data is really ok is a waste of time.

I would suggest this systematic review by Cochrane Database Syst Rev

Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2005(2):CD004137.

Briefly

A Cochrane review concluded that both NSAIDs and opioids provide effective relief from renal colic. Some evidence suggested that NSAIDs were more effective, and that opioid use was associated with more adverse effects, mainly vomiting. Trials included in this Cochrane review did not directly assess gastrointestinal bleeding or worsening of renal function. However, these potential adverse effects were infrequent in the Cochrane review and in a previously published meta-analysis of NSAIDs for renal colic ( Labrecque M, Dostaler LP, Rousselle R, Nguyen T, Poirier S. Efficacy of nonsteroidal anti-inflammatory drugs in the treatment of acute renal colic: a meta-analysis. Arch Intern Med. 1994;154(12):1381–1387).

Treatment harms are important, and trials designed to show if NSAIDs pose a risk in kidney stone treatment would be helpful. However, based on a paucity of evidence that NSAIDs are harmful in most patients with kidney stones, physicians should not exclude NSAIDs as an option for relieving renal colic.

These following comments were from "Am Fam Physician. 2012 Jun 15;85(12):1127. by CHARLES CARTER, MD, FAAFP"

Best regards,

Wisit

Absolutely from several vantage points do opiate pain killers taken outside an acute condition setting prevent true healing, introduce new challenges to well-being, and represent egregious health practice. It is the cause of so much suffering in the US that deaths from their use represent a greater threat than do automobile deaths on the highway. I am attaching one of my consumer monographs on the topic here. 

currently there is no validated questionnaire that can distinguish muscles over other sources of pain.  Physical exam still remains the most relabel way of establishing myalgia or fibromyalgia.

Crepitation suggests sever chondromalacia (gr II and III). I have no experience with the measuring the level of destroying enzymes.

For renal transplant recipients, we use Epidural Anesthesia and use fentanil with ropivacaine 0,2% In PCA post operatively. For donor, we use thoracic epidural in conjuction with GA.

PAIN RELIEF FOR POSTOPERATIVE PATIENTS

The most effective single dose oral analgesics for acute postoperative pain in adults have been identified by Oxford researchers in a Cochrane review of 45,000 participants across 350 studies.

Over 70% of participants with moderate or severe acute pain who took a single-dose achieved good pain relief with 120mg etoricoxib (Arcoxia) or the combination of 500mg paracetamol plus 200mg ibuprofen.

With other drugs, such as 1,000mg aspirin and 600mg paracetamol taken on their own, only 35% benefitted.

The worst was codeine, with only 14% getting significant pain relief. The period over which pain was relieved also varied, from about two hours to about 20 hours.

So everyone is different and you will find what works for you. It may be different to that which works for your friends.

We want to know if there is some kind of cut-off score that correlates with a minimal clinical improvement/deterioration. For instance a patient scores 74/78 on intake, during the intervention he scored a 62/78. How can this be interpreted? Can one say that he actually has a 'better' quality of life? 

I concur with Johannes - the other problem with SCS is that the person is, from that time onwards, a patient of your service. Developing effective coping strategies, understanding that this pain is not an indication of harm, and judicious use of blocks/sympathectomy is far less prone to complications.

Hi Michelle. The move of hydrocodone to Schedule II isn't just being considered, it is going to happen effective October 6, 2014. (DEA Final Rule published August 22, 2014 - http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-19922.pdf ). And Tramadol was made a Schedule IV drug by DEA effective August 18, 2014 (http://www.gpo.gov/fdsys/pkg/FR-2014-07-02/pdf/2014-15548.pdf ). For prescribers with Schedule II privileges, I would guess that not much will change, but I agree with Barry that codeine may well make a comeback.

In terms of identifying indicators to help determine more safe versus less safe opioid prescribing practices for quality improvement (and potential research), I recommend to look at frequency of certain physician behaviors that can be verified through more than one source during chart review.  Frequency of office visits, frequency of urine drug testing (that takes into account the frequency of office visits), frequency of prescription refill requests without an office visit, documentation of use of risk assessment tools (such as the ORT mentioned by Vahid Mohabbati), use of a pain medication agreement, documentation of at least one discrete and specific pain diagnosis, and co-prescription of riskier medications such as benzodiazepines (as mentioned by Yacov Fogelman).  These can be identified in the chart and verified by cross-referencing with lab results, pharmacy records, charges billed, etc. For some general examples of how this has been done, you may want to see the following articles:

Yanni LM, Weaver MF, Johnson BA, et al: Management of chronic nonmalignant pain: A needs assessment in an Internal Medicine Resident Continuity Clinic. J Opioid Manage 2008;4:201-211.

Chelminski PR, Ives TJ, Felix KM, et al: A primary care, multi-disciplinary disease management program for opioid treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005;5:3.

Adams NJ, Plane MB, Fleming MF, et al: Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001;22:791-796.

You might like to look at this recent systematic review paper

Physiotherapy 100 (2014) 220–227

Systematic review;The effectiveness of therapeutic exercise for joint hypermobilitysyndrome: Palmer et al

Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.physio.2013.09.002

Dear Fred

This article may be useful for you

J Vasc Interv Radiol. 2014 May;25(5):725-33.

Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management.

Phillips D1, Deipolyi AR2, Hesketh RL3, Midia M4, Oklu R

The scientific society knows, dear Gabor, that there totally no evidence for your ideas. Sorry!

We are (University of Talca, Chile) using a TMD Ohip- related quality of Life developed by J, DURHAM from newcastle University. 20 original question from OHIP-49 and 2 new Questions tested with a high Cronbach alpha. Journal of Oral Rehabilitation 2011 38; 871–883. Thanks for share.

Pain post tonsillectomy particularly reaches a peak in most cases at day 6 post surgery. NSAIDs are the most effective analgesics. Pain control is optimised by education (make patient aware pain and earache worsens rather than improves up to day six), use of the jaw (chewing gum is a useful ajunct, patients need to be educated to avoid living on a soft diet) and possibly steroids.

Opiates are less effective in the days following surgery

How did you measure the onset of effect Lucie. Did you do an EEG look at the Bispectral index?

This is a difficult question to answer. As I'm sure you know, most economic models for the management of any chronic illness vary considerably in depth and breadth and I have personally struggled quite a bit to incorporate models of direct and indirect cost into my own chronic pain research. I'm aware of a few manuscripts that describe the general cost of chronic pain management programs (see Gatchel & Okifuji, 2006 for an example), but I am unaware of any prospective comparative trials with a strong economic endpoint. Most seem to agree that information about healthcare utilization patterns before and after an intervention can serve as a reasonable surrogate for more refined cost models, but I have yet to see any studies advance this line of research beyond basic measures of disability and absenteeism (missed work time). I personally believe that studies of work presenteeism (present at work, but less productive) are sorely needed. For a few of my manuscripts I have actually counted the # of appointments attended in general and specialty clinics to represent healthcare utilization, but this method is only as reliable as the medical records reviewed for the count. This count revealed a significant decrease in healthcare utilization after self-management intervention (but I did not compare head-to-head with other interventions). It may also be good enough to ask patients to recall the number of visits for care to study utilization, though I don't know how reliable these data would be compared to medical record review. I suspect that more detailed cost estimates would support your suspicion that self-management offers significant long-term cost benefits.

Certainly few scientists are working on this principle and they have got some success also .Main issues are of Reproducibility and reliability.

Pls check the published works of Dr.Anirudha Joshi as well as Mr. Bharat S. Shete on Pulse diagnosis.

As per principles of Ayurveda Vata Nadi should be predominant in conditions of pain.You may get some relation between intensity of pain and pressure in Vatnadi.Understanding Nadi actually comes by experience and its not just pressure in Nadi which is felt but its movement,Rythm and relation to other nadis .Hence i will advice to first understand the entire concept of how Nadi is examined .Ideally involve some Nadi expert in your work.Look at concept of reading Nadi in its totality.Isolated approach towards Nadi may may be incomplete and can lead to failure.

Its really good work,But difficult to accomplish.

If possible contact SVYASA university in Bangalore .They are also working on this concept.

Wish you success in your Work

Gabapentin affects voltage-dependent calcium channel subunit alpha-2/delta-1 (CACNA2D1). If this channel were associated with acute pain mechanisms (peripheral or central), one would think the drug to be useful in pre-op or post-op regimens. However, there is no evidence to suggest this action. Subsequently, there is really no scientific rationale to administer the drug peri-operatively. Alternatively, with some injury/trauma/surgery, CACNA2D1 is known to upregulate in the nervous system and it is this change that facilitates the beneficial actions of the drug.

I just looked over the article. I was vaguely familiar with this approach back in the 1980's when I was involved in reviewing the literature. It appears you and others are making progress in improving the efficiency. In relation to my own interests, have you or others looked specifically at a uniform common migraine group versus classic migraines in your treatment since I suspect these represent two distinct populations. Additonally, have you done this directly with the temporalis muscle on the affected side or have you used other sites? What kind of long term effects do you get or does this mainly provide immediate symptomatic relief only? I think two interesting aspects. One would be to look at common migraine patients versus classic migraine versus no pain controls and to have the patients clench their teeth for several minutes (maximum of 5 probably) or until the pain was judged unbearable. With no pain controls this is known to create pain that resolves fairly quickly. The question would be whether this leads to the characteristic headache pain in the common migraine versus the classic migraine patients. If so, a second study could be whether the treatment you discussed would differentially affect common versus classic migraine patients. Additionally, if the common migraine patients were to develop pain following clenching, could your technique alleviate the pain? Just some initial thoughts. I am unsure as to whether any of these studies may have already been done. Bob

As Mr. Enrique has suggested, severety of post operative pain can vary with the type of surgery (caesarean to open chest surgery, amputation or tumour removal. The mechanism of pain varies, the mode should vary and as Mr Borja suggested, multimodal and rotatory schedule with multiple agents suits peri and immediate post op. pain management (to manage inflammation, release of endotheins by tumour cells leading to pain, neuropathic pain etc.). As you suggested, the least invasive mode is intramuscular or oral, which works well with caesarean patients, and good old practice of acupuncture. This case needs a meta analysis on the use of oral or intramuscular route.

The surgical when compared with conservative treatment shows no difference in the results particularly in ROM and stability.(my personal experience)

Functional treatment with a short period of protection and early weight-bearing, followed by physiotherapy is my option in the majority of the patients. I think the surgical treatment may be superior in selected cases , for example, in a person who is skilled in competitive track and field events (athletics)

For the treatment of diabetic neuropathy we use intraosseous blockade with excellent results. www.pain-clinic.ru

For simple performance tasks - timed repeated (x5) sit-to-stand and gait (50 foot speed walk (from which gait speed can be calculated and six minute distance test for an endurant component (Simmonds et al, Spine, 1998). We also use the BPI for pain. We have just done a study with Veterans in chronic pain and on opioids - using these outcomes. Note that self reports of function and measured function are complementary and you need both

Maybe with studies that show the burden of pain in our society, and this burden assesses with the morbidity, disability, emotional consequences and lose of quality of life.

@Bronnie

We are not in disagreement at all I think. I have never disputed, nor am I reluctant to integrate the psychosocial with the biological aspects of pain when discussing the theoretical aspects of pain. It is just that you and I probably see, in the main, the opposite ends of the spectrum While most of my patients have a "bio" component that predominates in terms of treatment needs and the psychosocial is along for the ride, I suspect you see the other end where the "bio" is so buried in the psychosocial dimension that the bio seems incapable of being teased out from the complexity of the florid chronic pain patient. I do see these patients too but less frequently. Even the most obvious 'bio' case - like a fracture or a wound carries with it the learned experiences and responses to past instances of pain woven into a behaviour pattern. This is why one patient with bones sticking out of the leg will grit his teeth and make humorous comments to the ambulance officers about how he will have to put off the Tongariro traverse until next month, while another will scream and cry, wail and moan as if he will be crippled and in pain forever. The injury is the same but the responses are different. The treatment - at least initially is not that different though - provide relief from nociceptive input, reduce the fracture, stabilize it and let nature do the physical healing. However, the different responses are cues to how pain relief and rehab should proceed. They are cues only however. I have seen the former patient become disabled and chronically painful because of poor management and interaction with the health care system despite the initial rather positive response type. Conversely I have seen the latter case calm down rapidly once pain is under control and proceed through rehab without a hitch despite the initial 'yellow flag' type of behavour initially.

My point here is that the clinician must be responsive to what is needed when it is needed, and not doctrinaire in either direction about what approach or mixtures of approach are needed, for it can and does change from patient to patient, and for any given patient throughout the process of acute presentation to rehabilitation.

Again, I reiterate, I have no quibble with your statement "..that psychological and social factors are present in all experiences of pain." Absolutely correct - we are not insects but perceptual / cognitive / emotional entities, enormously complex and individually unique. Nociception is a primitive sensory level data input and pain is the experience of, and the behaviour in response to, that sensory input. I think pain arising completely de novo is rather rare is it not?

And from a more informal perspective based on my clinical experience, people who have slept well have more energy and resilience to cope with stressors in general during the day. Pain is a stressor, so good sleep probably helps.

These are a couple of good papers:

1.

When is pain related to emotional distress and daily functioning in fibromyalgia syndrome? The mediating roles of self-efficacy and sleep quality.

Miro, Elena; Martinez, Maria Pilar; Sanchez, Ana Isabel; Prados, German; Medina, Ana.

British Journal of Health Psychology. Vol.16(4), Nov 2011, pp. 799-814.

2.

The association between chronic low back pain and sleep: A systematic review.

Kelly, Grainne A; Blake, Catherine; Power, Camillus K; O'Keeffe, Declan; Fullen, Brona M.

The Clinical Journal of Pain. Vol.27(2), Feb 2011, pp. 169-181.

3.

Intraindividual variability in daily sleep and pain ratings among chronic pain patients: Bidirectional association and the role of negative mood.

O'Brien, Erin M; Waxenberg, Lori B; Atchison, James W; Gremillion, Henry A; Staud, Roland M; McCrae, Christina S; Robinson, Michael E.

The Clinical Journal of Pain. Vol.27(5), Jun 2011, pp. 425-433.

I usually recommend just 1 time injection, and I check again within a week. If pain decreased more than 50% and their motor function is not worsed, I prescribed oral medications for PRN usage. If not, especially worsening motor fuction, I recomment decompression, endoscopically or microscopically. Response of 1 st injection is the key to differenciate ....

In Germany, the suggested maximum daily intake of Paracetamol is 4000mg per person. So even if he takes the 500mg 3 times a day he'd still be fine. For the liver, really more the acute intoxication (-> producing the toxic metabolites) is the thing to worry about not so much the ongoing intake; and as you're checking his liver enzymes already he should be absolutely fine.

Also there is a combination drug (Contraneural® Paracetamol/Codein) that has 500mg Paracetamol and 30mg of Codein. From the guidelines it says that you can take it up to 8 times a day. So also with the Codein he should be fine.

If he'd be addicted to the codein you should generally see either some craving, increase in dosage or abstinence phenomena. At least you didn't mention anything about an increase in dosage.

In general I think he's fine with that dosage of Codein and Paracetamol.

What I'd take care of is an Analgesic Nephropathy as he's using a combination of these drugs. So you might want to monitor his kidney function.

Best

Sebastian

I too am curious how in 2012 you would not first check the Pt's CYP-450 and opioid response Hx and then decide what would be the most genomically indicated single opioid for the specific outcome decided upon with the Pt and the family. I too fail to see the benefit of 2 vs. 1 specific agent. On Linda's point about "pain control specialist physicians," and especially hospital physicians, if I want to increase the chances of my Pt's obtaining improved pain control, I tell them how to go about checking the prescribing physician's credentials in their putative pain medicine specialty. And, if it doesn't exist, I advise the Pt to "walk" (right out of the "pain doctor's" office). Pain control is best provided today in this period of scarce resources by reducing doctor-caused error, because of documentable competence in managing of opioids, espeically when complications develop.